Pre-VIsit History Form - BridgeMill Animal Hospital - Canton, GA

BridgeMill Animal Hospital

9560 Bells Ferry Road
Canton, GA 30114

(770)479-2200

www.bridgemillvet.com

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Pre-Visit History Form

Please complete this form prior to your pet's appointment, even if your pet's condition has not changed since his/her last visit. The information that you provide will help streamline your pet's visit during COVID-19 protocols and curbside care. 

Pre-Visit History Form Form

Today's Date: (required)

Patient Name: (required)

Species: (required)
Dog
Cat
Age/DOB: (required)

Gender: (required)
Male/Neutered
Male/Intact
Female/Spayed
Female/Intact
Unkown
Color: (required)

Breed: (required)

Appointment Date: (required)

Appointment Time: (required)

Who will be bringing your pet to their appointment (first and last name)? (required)

Vehicle (color/make/model): (required)

Best phone number to reach this person during this appointment: (required)

Email: (required)

Is this person authorized to make medical decisions for this patient? (required)
Yes
No
What is the primary reason for this appointment? (Please be as detailed as possible about any concerns, including any new lumps/bumps, behavior changes, or changes in mobility): (required)

Has your pet been in contact with anyone diagnosed with or suspicious for COVID-19 in the past 2 weeks? (required)
Yes
No
Do you have pet insurance for this pet? (required)
Yes
No
Which flea/tick medication do you use? (required)

Last date given: (required)

List all other medications and supplements your pet is currently taking (medication/supplement name, dose, frequency): (required)

Do you need refills of any medications/supplements today? (required)
Yes
No
What are you feeding? (required)
Wet food only
Dry food only
Mixture of wet & dry food
People food
Raw diet
Home-cooked diet
Treats/other
Do you need refills of any prescription diets? (required)
Yes
No
How is your pet's appetite? (required)
Normal
Increased
Decreased
Comments:

How is your pet's thirst level? (required)
Normal
Increased
Decreased
Comments:

Has your pet had any nausea, vomiting or regurgitation? (required)
Yes
No
How are your pet's bowel movements? (required)
Normal
Abnormal
Does your pet experience flatulence (gas)? (required)
Yes
No
How is your pet's urination? (required)
Normal
Abnormal
How is your pet's energy/activity level? (required)
Normal
Abnormal
Comments:

Please check which, if any, your pet has experienced in the past 2 weeks:
Coughing
Sneezing
Has your pet ever had a seizure? (required)
Yes
No
Does your pet have any behavior issues? (required)
Yes
No
Do you provide any home dental care? (required)
Yes
No
Has your pet been prescribed any anti-anxiety medications to help decrease fear, anxiety or stress during vet visits? (required)
Yes
No
Is there any thing else you would like to discuss during your pet's visit today? (required)
Yes
No
APPOINTMENT PROCEDURES:
(required)
I understand that access to the BridgeMill Animal Hospital building is limited to employees and pet patients only at this time due to the COVID-19 pandemic. For everyone’s safety, I understand that I must wear a facemask at all times during any direct interactions with the BridgeMill Animal Hospital team.
I understand that payment is due in full at the time services are rendered. This includes services authorized by my proxy, by another responsible party listed on my account, and/or by phone.

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